02/28/2021 CS321629-P 1

COVID-19 Vaccine 

Vaccine Administration Competencies 

Assessment Form

As COVID-19 vaccines become more widely available, it is crucial that they are safely and effectively administered 

to as many eligible recipients as possible. This requires knowledgeable, confident, and competent vaccinators and 

support staff. It is vital that anyone preparing and administering vaccine be properly trained and given the time and 

opportunity to practice these skills (under supervision when needed).

Supervisors

Use this form to observe staff's readiness to perform assigned functions. Observe their performance as they 

prepare vaccine or administer vaccine to several recipients and score in the Supervisor Review columns. If 

improvement is needed, meet with them to develop a Plan of Action for additional training or practice they 

should undertake to achieve the level of competency you expect. Write desired actions for each competency 

that needs to be addressed. This form may also be used to assist with more formal performance reviews.

For Self-Assessment

Review the competency areas below and the core skills, techniques, and procedures outlined for each 

area. Score yourself in the Self-Assessment column. If you check “Needs to Improve,” you indicate further 

study, practice, or change is needed. If you check “Meets or Exceeds,” you indicate that you believe you are 

performing at the expected or higher level of competence.

Who can be assessed using this form:

• Experienced vaccinators

• Vaccinators who have not administered vaccines in the past 12 months or longer

• Medical support staff who are not licensed to administer vaccines but assist with vaccine 

preparation and cold chain management

• Healthcare providers who require documentation of an observation period as part of the 

Declaration under the Public Readiness and Emergency Preparation (PREP) Act for Medical 

Countermeasures Against COVID-19

• Administrative support staff who assist with cold chain management, data reporting, and 

distribution of required materials to vaccine recipients
02/28/2021 CS321629-P 2

COVID-19 Vaccine 

Vaccine Administration Competencies 

Assessment Form

Self-Assessment Supervisor Review

Core Skills, Techniques, and Procedures N/A Needs to 

Improve

Meets or 

Exceeds

Needs to 

Improve

Meets or 

Exceeds

Plan of 

Action*

Vaccine 

Product 

Knowledge

1. Completes COVID-19 vaccine training and 

additional training as needed.1 

2. Understands clinical guidance and can accurately 

assess and vaccinate based on:

• eligibility requirements 

• vaccination schedule and history

• contraindications 

• precautions

• clinical considerations

3. Understands post-vaccination clinical guidance, 

including:

• recommended observation times

• signs and symptoms of allergic reactions 

and anaphylaxis

4. Explains how the vaccine works, major vaccine 

components, and side effects.

Storage and 

Handling

1. Demonstrates knowledge of proper 

procedures when managing vaccine shipments, 

including inspecting, unpacking, accounting, 

and storing vaccines.

2. Explains the cold chain requirement for the specific 

COVID-19 vaccine product(s) used at the facility, 

including protocol(s) in case of temperature 

excursions or cold chain failure.

3. Demonstrates use of proper temperature 

monitoring and recording process for the 

facility, including the process for handling 

a temperature excursion.

4. Demonstrates understanding of all procedures 

necessary to prepare and transport vaccine 

product(s) between facilities.
02/28/2021 CS321629-P 3

COVID-19 Vaccine 

Vaccine Administration Competencies 

Assessment Form

Self-Assessment Supervisor* Review

Core Skills, Techniques, and Procedures N/A Needs to 

Improve

Meets or 

Exceeds

Needs to 

Improve

Meets or 

Exceeds

Plan of 

Action

Administration 1. Shows proficiency in infection prevention 

and control measures, including COVID-19 

mitigation measures.

2. Prepares vaccine following manufacturer 

instructions and CDC recommendations.

3. Shows proficiency in injection practices:

• Correctly identifies the proper needle gauge 

and length based on route.

• Correctly identifies the proper injection 

site based on route and age of the vaccine 

recipient age.

• Demonstrates correct intramuscular 

injection technique.

• Identifies strategies to prevent vaccine 

administration errors, including shoulder 

injury related to vaccine administration. 

4. Disposes of vaccine vials, needles, syringes, 

and other supplies correctly, as per standard 

precautions.

Documentation

1. Completes required documentation of 

vaccination in appropriate data systems.

2. Provides appropriate information and 

documentation to vaccine recipients, including 

the COVID-19 Vaccination Record Card and 

the EUA Fact Sheet for Vaccine Recipients and 

Caregivers, which are required by law.

3. Demonstrates knowledge of the Vaccine 

Adverse Event Reporting System (VAERS) and 

reporting requirements. 
02/28/2021 CS321629-P 4

COVID-19 Vaccine 

Vaccine Administration Competencies 

Assessment Form

*Plan of Action

Write steps that should be taken based on the list of options below. Also include an agreed upon deadline for completion 

and date for follow-up, if necessary. Keep in mind that sometimes more than one action step may need to be taken for a 

specific skill or technique, and that various action steps can be used across skills and techniques. 

Action Items to Consider:

a. Complete the related CDC training (available at 

https://www.cdc.gov/vaccines/covid-19/training.html).

b. Review vaccine-specific materials and web pages 

(available at https://www.cdc.gov/vaccines/covid-19/

info-by-product/index.html).

c. Review clinical considerations (listed at https://www.

cdc.gov/vaccines/covid-19/info-by-product/clinicalconsiderations.html).

d. Review Emergency Use Authorization (EUA) 

for the relevant vaccine (available at https://www.fda.

gov/emergency-preparedness-and-response/mcmlegal-regulatory-and-policy-framework/emergency-useauthorization). 

e. Review vaccine storage and handling resources 

(listed on https://www.cdc.gov/vaccines/covid-19/infoby-product/index.html).

f. Observe other staff working with vaccine recipients.

g. Practice giving an injection.

h. Practice answering questions from vaccine recipients by 

role-playing interactions with other staff.

i. Review the COVID-19 Vaccine Addendum in CDC’s 

Vaccine Storage and Handling Toolkit (available at 

https://www.cdc.gov/vaccines/hcp/admin/storage/

toolkit/index.html). 

j. Shadow experienced support staff to observe proper 

storage and handling procedures. 

k. Observe support staff as they complete 

documentation processes.

l. Review information on data systems and practice 

navigating these systems while supervised.

m. Review where the COVID-19 Vaccination Record Card and 

the EUA Fact Sheet for Vaccine Recipients and Caregivers 

are kept for distribution.

n. Other: ________________________________________

File this checklist with personnel information and review as necessary.

PLAN OF ACTION DEADLINE DATE OF NEXT PERFORMANCE REVIEW

EMPLOYEE SIGNATURE DATE SUPERVISOR SIGNATURE DATE